Are we experiencing mass burnout in healthcare?
- page 5

This was written in response to a thread where a nurse experienced lateral violence at the hands of her preceptor. I thought it would be an appropriate discussion to start in this area. Thoughts?
... Read More

What I am really good at is assessing the patient, listening to them, interpreting the S&S they describe and putting it into "doctorese" so they can obtain apropriate treatment. I am also a good caregiver in that I can make someone feel better with a footbath while they talk, for instance: things that make up the magic of nursing, in short. I like to research their disease and find nursing interventions that address the discomfort they are having. This is good for chronic diseases as well as acute. Once I had care of a person who had Gastroparesis, among other things. This person started spewing Tube feed out of his mouth.The LVN who came on gave him an injection of Ondansetron. However I had managed the problem before by checking the residual (350ml!) and turning off the pump as necessary to tolerate the feed, assessing for constipation, etc, and recommending a lower rate, or just actually informing the DR of the findings. The LVN was "more efficient" according to the powers that be, and was a more desirable employee as the LVN finished the paperwork and task faster, problem solved. This is a terrible risk for aspiration, and misery. It kind of demonstrates the value of an RN. How many times have we seen a DR who says "Oh, you have nausea, take this..." when the problem is something like aversion to pureed chicken, as an example. This type of nursing takes time and thought but pushing meds seems to be the priority all too often. I don't know what this has to do with activism exactly but I think I am talking about the kind of slapdash nursing that is in vogue now in some places. I suspect Florence did a lot with just observation and caring. I wish we had the gift of time.

Medicare rejects just about every bill that is submitted. We submitt scripts for meds every three months and Medicare rejects them in January, April, July, and Oct every time. Same med, same chronic illness, same patient.

Kidney:

Yikes, this just compounds an already overwhelming problem. This adds to the paperwork to the desks of Ambulatory Care nurses and causes the patient to have to wait, and wait, and wait! I know this to be true because I worked in Outpatient Cardiology. I can tell you that making a call to an insurance company about a prior authorization was my least favorite task. It was terribly unproductive and frustrating! I can recall times where I nearly cried! This is a great example of how paperwork imposed upon us unnecessarily by insurance companies keeps us from doing what we should, taking care of patients. Thanks for bringing this issue to light. Best! Tabitha

This is an insightful post. I am right there with you on health insurance reform. It isn't a republican, democrat, liberal, conservative, or socialist issue; in my estimation, it's a human rights issue.

I agree also that according to their scope and practice, nurses of all educational preparation bring infinite value to the profession. I have wondered on occasion if "the powers that be" will further dilute the role of the RN by assigning what used to be RN roles out to LPNs and CNAs. I am hoping that this is not the wave of the future or else we all may be looking for jobs. In this respect, I do advocate for keeping RN roles, RN roles or else we may be challenged to justify our continued existence in certain practice areas. Take dialysis for example. There are many clinics that use dialysis techs for the most part and provide minimal nursing oversight. Dialysis is not a benign procedure and it certainly requires vigilance on the part of the nurse to interpret lab values and make nursing decisions based upon assessment of the patient. This is one small example of how RNs are being replaced by unlicensed assistive personnel. Don't be surprised to see licensing/certification programs crop up in the near future for all sorts of nursing related duties. Another example is the practice of CNAs delivering medications in some LTC environments. We have to protect the scope and practice of an RN because it is the right thing to do for the patient.

Would you mind elaborating on the duties that were added to your load as a result of union intervention? I am interested in hearing more about your experiences.

Profit or Not-for-Profit, the motivation appears to be the same and that is, PROFIT! The revenues are just distributed differently.

Medical insurance providers are definitely earning a pretty penny and our patients are paying the price! The same is true of medical malpractice insurance companies. What a mess! They are price-gouging docs who have no choice but to participate in the monopolies. What about tort-reform? Mercy! While many lawsuits are frivolous, tort reform has resulted in the inability to receive any justice with regard to acts of harm committed against them. Take Texas for example. Doctors are flocking there in droves to set up shop as a result of the extensive tort reform in the state. It has become unprofitable for attorneys to take on most med malpractice cases and as such, the patients are left without a legal advocate when they are harmed.

Thanks for your thoughts!

Tabitha

I expressed these very same sentiments several years ago on this listserve. Hospitals and health care providers replacing RNs with yet another "flavor", of unlicensed, assistive, personnel, with the goals being, to run an health care organization with as few, or no, RNs. And this was before "medication aides" became all the rage in nursing homes and assisted living facillities.

All of this de-skilling came about with the assistance (blessing) of our State Boards of Nursing, and State Nursing Associations. They are selling out the nursing profession, and ultimately, our patients. You don't see the State Board of Education advocating for the replacement of teachers with unlicensed teaching assistants, or HS dropouts hired off of the street. Why is that? Because teachers are unified nationally, and carry carry alot of clout and power.We can learn alot from them. I could be mistken,but no one ever died because they could not do long division, or diagram a sentence, but almot 100, 000 people die of medical errors every year.

And make no mistake, our low level of education are contributing to our demise.We are only one educational level away from the unlicensed assistive personnel who are replacing us in the workplace. All other health care professions have increased their entry into practice, but nursing ads scream about on line nursing degrees at the drop of a hat. No one is replacing teachers, pharmacists, PTs OTs etc ,with HS dropouts. Folks, this does affect our credibility in the workplace.

All of you nurses who refuse to unionize or support a National Nurses Organization, are also selling out your patients. You cannot advocate for yourself with the same power and effect that a national, powerful organization can. You are kidding your self if you think that you can.

While you sit and fiddle while Rome burns, hospitals and nursing homes have been busy stealing away our professional practice. There will be a point of no return, when they can say, "we have been able to function just dandy without RNs, or LPNs, why continue to support a groups that we have proven that we can do without?" And at the rate we are going, we are a generation away from that day. Think outside the box. JMHO and my NY $0.02.

What a powerful and thought-provoking message you bring to the table. I am most invigorated by your idea that we "think outside the box." You are spot-on with this sentiment. If we keep doing the same old thing we've done, we will keep on getting the same old thing we've gotten (paraphrasing Einstein here). It is going to be difficult to effect monumental global changes within the nursing profession without a national voice who is willing to make decisions that might be unpopular with the administrative masterminds. I am reluctant to say with definitive conviction that the ANA is not the national voice we need; however, these isn't a whole lot of evidence to support their ability or willingness to effect the changes that are so desperately needed in healthcare. We can post position statements all day on staffing acuity models, safe ratios, and quality nursing care, but until we collectively demand legislation that would guarantee the above, nothing will change and our patients will continue to suffer needlessly. I'd be interested in anyone who can provide evidence contrary to what is most assuredly my humble yet researched opinion. I would like nothing more than to have my faith restored that the MY major professional advocate is working hard to enact legislation that would allow me to safely perform the job that I love so much. Why is it that this one healthcare political hot-button is so dangerous for the ANA to actively pursue? Clearly, nurse-to-patient ratios is one of the most important issues on the table in our present practice environment.

Thanks for your insight, Lindarn. What's happening in Washington with regard to nursing advocacy? What are your ratios like there?

What I am really good at is assessing the patient, listening to them, interpreting the S&S they describe and putting it into "doctorese" so they can obtain apropriate treatment. I am also a good caregiver in that I can make someone feel better with a footbath while they talk, for instance: things that make up the magic of nursing, in short. I like to research their disease and find nursing interventions that address the discomfort they are having. This is good for chronic diseases as well as acute. Once I had care of a person who had Gastroparesis, among other things. This person started spewing Tube feed out of his mouth.The LVN who came on gave him an injection of Ondansetron. However I had managed the problem before by checking the residual (350ml!) and turning off the pump as necessary to tolerate the feed, assessing for constipation, etc, and recommending a lower rate, or just actually informing the DR of the findings. The LVN was "more efficient" according to the powers that be, and was a more desirable employee as the LVN finished the paperwork and task faster, problem solved. This is a terrible risk for aspiration, and misery. It kind of demonstrates the value of an RN. How many times have we seen a DR who says "Oh, you have nausea, take this..." when the problem is something like aversion to pureed chicken, as an example. This type of nursing takes time and thought but pushing meds seems to be the priority all too often. I don't know what this has to do with activism exactly but I think I am talking about the kind of slapdash nursing that is in vogue now in some places. I suspect Florence did a lot with just observation and caring. I wish we had the gift of time.

I love this! You have hit the nail on the head! We must use our ears to listen to our patients and their bowel, lung, and heart sounds, our eyes to inspect, our hands to palpate, our arms to hug, and our hearts to care about doing the right thing each and every time for our patients. There is no way to measure or quantify many of the interventions we perform as nurses and commonsense will tell you that rushing through nursing care will result in increased errors. Come'on!

Nobody has ever measured, not even poets, how much the heart can hold.
— Zelda Fitzgerald

I really enjoyed your posting, especially the part about how we as RNs seem to do a lot more Practical Nursing than that which makes our profession unique. What is it that makes our profession unique anymore? I'd like to hear more of your thoughts around this since I think you made an excellent point that there doesn't seem to be enough time in a given shift to do much in the way of critical thinking. Have you noticed RNs doing less assessing than what we were taught was necessary in school? I know that the nursing process is hammered into our heads in school, but I think the principles are still quite valid and result in quality patient care when utilized appropriately.

Ok, Miss Tabitha, you appear to be the new Sister Simone Roach! And the internet is the new "book" that you should write. Ok so we all agree that something is wrong, and like politicians we can go on stating the problems that we find and we all will nod our head and say..YES! But let's do this...we must come up with a catchy phrase that will get people's attention and that will epitomize our ideals. Then we will have to find ONE THING to will ask for and then go on to find other things little by little. Brainstorm, guys...any ideas for a good movement slogan? Can we get together on this? Ideas anyone?

That one little thing may be a mass campaign to educate nurses and healthcare consumers across the country about S. 1031. Our voice, by numbers alone, can literally flood each and every one of our local decision-makers with enough push to do the right thing in support of safe nursing practice and patient care. So, one practical step is to really educate each and every person we know about this bill. Herring, what does the timeline look like?

GoodNeighbor, I think I will take the comparison of me and Sister Simone Roach as the most inspiring complement I've ever been paid by another nurse. Oh, there was a patient and his family that hunted me down on Facebook once simply to express gratitude for the care I'd given them in the Emergency Department. He said, "You made me glad that I got pneumonia." If this patient only knew that while he may have found healing in me, I also found healing in him. I would have to say that this is definitely why I advocate so passionately for our Nurses and patients. I have made the personal journey from apathy and disengagement to wounded healer and I will never ever turn back.

Goodneighbor, we are going to have to hit this from a local level in order to garner enough support across the U.S. We will never effect change if the only nurses willing to stand up are those who live in California. Please, I mean no disrespect to nurses across the U.S. In fact, I have nothing but admiration for the plight of any nurse willing to navigate the muddy waters of healthcare in our country. It isn't for the weak and faint of heart. I am only suggesting here that many nurses are reluctant to advocate for change because it may mean risking their livelihood. I have come to the sobering realization that I can no longer tolerate a system that sets me up to fail with regard to my personal ability to deliver the highest quality nursing care. I also got this crazy idea in my head that my logic had been flawed for a number of years. How can I possibly be afraid to stand up for the rights of my patients to receive the very best that healthcare has to offer? Advocating for safe Nurse-to-Patient ratios will benefit each and every nurse and patient and as such, I have grown extraordinarily frustrated and weary of a system that would seek to define such advocacy as subversive. This is a smokescreen which is meant to detract from the point at hand, a red herring, if you will. Advocating for safe nurse-to-patient ratios is not the same as advocating for unions in healthcare systems. Truth be told, and according to my personal opinion, the potential exists that unions would become obsolete if healthcare systems were willing to do the right thing with regard to their patients and staff all the time.

So, in order to bring real change to nursing practice, we will need to identify leaders in each and every state across the country to champion the message through a variety of media. These would include local print media, radio, television, the creation of state non-profits with web coverage to a wider audience, and by word of mouth. In order to be successful, we will need to mount a grassroots campaign with very active participants in each state.

I, like you, have no intention of writing another position paper which restates a problem which we are all well aware of. I am so energized by your interest because at times, it has been a very lonely path to walk and it's great to hear that someone all the way up in Washington State is interested in standing up for our patients and our profession.

I think that one angle we can take as nursing professionals is that we can focus on the idea that "Nurses Save Lives." We are arguably the driver of healthcare quality and our interventions or lack thereof make a measurable difference in the outcomes of our patients in terms of morbidity and mortality. If the U.S. healthcare system would like to realize improvements in healthcare quality, it makes good sense to start with nurses since so many outcome measures are nurse-driven and/or sensitive. More Nurses = Lives Saved! 98,000 patients dead each year? Unforgivable and blatant negligence, some would argue. The most important decisions and interventions we make as nurses find their birth in our ability to think critically through the pathophysiology of complex disease processes, symptomatology, and a myriad of other factors such as lab values, resources, and prioritization. These critical elements of Registered Nursing care will never be safely replaced by anyone with less education or qualifications. If they could, nurses would cease to exist on on the healthcare team.

Goodneighbor, I can imagine a world without nurses. Many of the nurses working in our hospitals today have checked out emotionally and still punch the time clock. Our interventions as advocates might be effective if aimed at restoring the hope, faith, and vigor into our disheartened sisters and brothers. My compassion extends beyond that which is aimed at our patients and their safety but also to my nursing peers.

Nurses are the true safety officers of any hospital and as such, we have every right and responsibility to advocate for a practice environment that ensures and promotes our ability to monitor and ensure that each "i" is dotted and every "t" is crossed. It is the right thing to do for our patients and we must mount a defense against anything that prevents us from giving the highest quality of care to our patients.

Goodneighbor, can we count on you to advocate for the nurses and patients of Washington State?

It isn't, of course, but you hear so many politicians worrying about wasteful spending, but I can't recall ever a word about Medicare abusing us, the healthcare system, by withholding timely payments. I've learned to expect that from private insurers, but I'm appalled that Medicare does it, too.

I really enjoyed your posting, especially the part about how we as RNs seem to do a lot more Practical Nursing than that which makes our profession unique. What is it that makes our profession unique anymore? I'd like to hear more of your thoughts around this since I think you made an excellent point that there doesn't seem to be enough time in a given shift to do much in the way of critical thinking. Have you noticed RNs doing less assessing than what we were taught was necessary in school? I know that the nursing process is hammered into our heads in school, but I think the principles are still quite valid and result in quality patient care when utilized appropriately.

Thanks again,

Tabitha

Thanks.

I think I'm in kind of an odd position, in that, until the last year or so, I was probably correct to blame myself for the trouble I sometimes had getting my work done. When you're new and inexperienced, something as simple as starting an IV can put you behind for the rest of your shift. And that old devil, time management, can take a while to develop. (Actually, I really dislike the whole idea of time management, in the sense that it's much too vague. But I'll concede that it fits for things like going in to change a dressing and finding you forgot half the supplies you need. On the other hand, doing a careful assessment or performing chest PT doesn't really seem like poor time management, does it?)
Still, one of my mentors prepared me, somewhat. First couple years, all you can think is, "Can I do this?" Next couple of years, you're kinda giddy as you realize, "Hey, I can do this!" But after that, you get to the point where you have to ask, "Should I be doing this?" For sure, the job has it's share of negatives, but I think I'm leaning toward I should be doing this. Some of the positives are pretty darned positive. And I do find that among all the many tasks, I do find some time to do the things that drew me to nursing in the first place. Like the night I had an ortho pt with intractable pain despite massive amounts of medication. I gave all the meds that were ordered, reported the lack of relief to the resident on call, cussed and kicked the Pyxis, but the best thing I did that shift was probably pulling up a chair and listening to her gripe for about ten minutes. She was on the call button a lot less, after that, and I think the demonstration that someone did care improved her pain tolerance a bit. Pain is depressing, and depression aggravates pain.
That example certainly isn't RN specific, and probably not a great example of critical thinking. It may sound surprising from a male (or maybe not) but I've come to view "critical feeling" as one of the more important aspects of nursing. In school, an instructor asked me why I chose a particular intervention on one of my careplans, and I answered truthfully, "It felt right." She affirmed the value of intuition, but quite properly also insisted I go back and find a scientific basis for whatever it was.

I agree with you that assessment is one of the most important, perhaps the single most important, parts of the nursing process. I've noticed that some of my coworkers seem to get through them awfully quickly. But I've learned to be a bit more flexible about what constitutes an assessment. I've had a couple of nights were my assessments were done one system at a time--put a patient back in bed, assess mental status. Put him on a bedpan, assess skin. Put him in restraints, assess circulation. Loosen restraints, assess respiration. And so on.
More typically, I try to do a complete head to toe at the start of my shift. Our standard of practice is that each patient must have a full head to toe in each 24 hr period, and our custom is that's done at midnight. I do them, but I take into consideration what I saw on my start of shift. Some patients need their butts checked every four hours, but some don't, and if there were no issues at 2000, they're likely okay at 2400. So my second head to toe is a bit focused, mostly out of consideration for patient comfort.
My 0400 is supposed to be a focal assesment, unless I'm in stepdown. On my unit, that generally means neuro checks and look at their vitals, which the aides usually collect, plus anything else that seems particularly relevent, like a dressing, and most patients need respiration and pulses checked, just because they can go so bad so quickly. My neuro checks, though, are often, "How do you feel? Do you need anything?"
I did one memorable assessment without a stethoscope. Pt was doing fine on her previous assessments, but whe I got there I'd forgotten my scope, but did have a pulse oximeter. Everything else was cool, so I joked that the pulse ox was a "lazy man's stethoscope." Then, later, we were chatting, and I found out she was a nursing instructor. Uh-oh!!! But she was okay with it, and even complimentary, and d/c'd the next morning.

So, now I'm doing charge, occassionally, and part of that is mentoring newer nurses who've completed orientation, but are still working through the "Can I do this?" phase, and one in particular is having a tough time setting priorities and managing her time. I see her notes, and they're amazingly complete. I've seen her fretting over charting--"We're those pupils 'brisk' or just 'normal'. Was it XXX or YYY that had an SpO2 of 96%?" Which would be great, if she didn't occassionally miss things that matter more. So I find myself encouraging her to be a bit "sloppier," in her practice, and that feels wierd. Still, I think there are times when practical nursing is more important than figuring out why a potassium level was 4.0 yesterday and is 3.9 today.

Wow, Tabitha, thank you for addressing your response/challenge to me! I wish I could write as well as you! Sure, I'll be happy to stand up for the nurses in Washington State, but I am in Texas and I'll have to stand here too! I will check to see what S103 is (some activist!). We have here Senate Bill SB476 regarding Nurse Staffing. ... Nursemike, you are inspiring also and help make it all worthwhile. Well, thinking about this discussion throughout my day I kind of thought that there was a tremendous PR thing going on about "the nursing shortage" that has been picked up by NYTimes, Newsweek etc. etc. It seems that it has been promulgated by some entity that somehow benefits by it(?) I have read a lot of posts and have friends that are trying to get jobs that are not there. Especially new nurses. Schedulers say they are going crazy trying to staff but everyone has a "hiring freeze". Witness the intense interest that was just shown in the part time Mollen vaccination clinics on our boards. Another thing I thought about is that it seems that Hospital Administrators at the top level perhaps seem to think of us a "glorified clerks".[i.e."Well, they're college educated, they must be able to fill out a few forms correctly"] It's as though they are so impressed with documentation that they conceive us as sitting at a desk orchestrating care by UAPs, Techs, transport aides, housekeeping--sort of like a foreman of the floor. And we learn so little of this in Nursing School. And we, silly things, want to deal in vomit and blood and pain. I can see them saying.."What do these women want!" (OK what do these PERSONS want) Yes we want it all. We want to have hands on with the patient and we want to handle the paperwork, doctor interface, community of care thing. I read a forty two page job description of charge nurse duties that, well, no one could do well for the patient load. I'd like to see some ideas of how we ourselves define our job; what we ourselves conceive as the role of the nurse. I'm still new and learning all the unwritten, unspoken aspects of the job. Sometimes I'd like to just ask: "What is our goal here-what are we really trying to accomplish?" Many times I've been surprised to see it wasn't what I thought it was.

Oh, it's wonderful. It's " A bill to amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes" You can do a search under S 1031. What do we do, write to our Congresspersons? Will have to get educated about this one!